By Jamie Waterall, National Lead for Cardiovascular Disease Prevention and Associate Deputy Chief Nurse at Public Health England, and Honorary Associate Professor at the University of Nottingham

Over recent weeks, we’ve seen constant media reporting about the increased pressures our health and care system is experiencing.

There’s no disputing that the NHS is facing ever greater demands, often linked to our aging population and many more people living with long-term conditions such as heart disease, diabetes, dementia and certain cancers.

But it’s worrying that most of the news reports only focus on the need for more acute hospital beds and ambulances, rather than discussing the need for a radical upgrade in prevention to reduce demand on these services.

As public health professionals we know that there are no easy solutions to the pressure on our health and care system. These are complex problems, requiring a whole-systems response.

However, we also know that many of the health issues keeping our hospitals so busy are preventable. Having worked in acute medicine and cardiology for a number of years I witnessed the scores of patients I treated who were admitted to hospital with conditions that could have been delayed or avoided altogether.

And when working in the acute trust environment, I would have agreed that more beds and acute services was the answer to our problems. It was not until I was working in primary care as a nurse consultant that I became more aware of the need for an increased focus on prevention.

So I frequently ask myself; how can we better harness the skills of our trusted front-line professionals, ensuring we all get behind this radical upgrade.

Our research informs us that there’s real appetite to build more prevention into our daily practice, however it also shows us that there can be barriers and challenges.

Time and resource is of course an issue, but we’ve heard that some professionals can be apprehensive about talking to members of the public about their weight, for instance, or whether they smoke or keep active. We also know that there can be uncertainty about the availability of local lifestyle services to refer patients to.

With all this in mind, Public Health England has developed All Our Health, a framework which supports all health and care professions to get more involved in the upgrade in prevention. It provides tools and advice to support ‘health promoting practice’ with quick links to evidence and impact measures and top tips on what works.

Based on user research we’re making improvements to All Our Health as well as forging new links with universities and Health Education England, so we can build more prevention into the way we train our future professionals to practise in this different world with new expectations and opportunities.

We also hope All Our Health will help health and care professionals to engage with the local public health system, including getting involved in the development of prevention initiatives.

Surveys of the public constantly show that our frontline health staff are amongst the most trusted professionals in our communities. Just imagine the impact if our estimated two million health and care staff built more prevention into their practice. We could truly achieve the radical upgrade we so urgently need to see.

For further information and to read more about All Our Health, click here.

Public health should be proud of the fact that we are an evidence-based profession. We have brought both the ethos and the tools of evidence-based clinical practice to the NHS and the wider public sector. However, we should not lose sight of the fact that public health is both a science and an art; this requires us to bring judgment to bear alongside evidence.

There are plenty of reasons that can be deployed in order not to use evidence. Sometimes issues can be seen as “blindingly obvious”; I recently saw a video of Brian Cox using the fact that we can actually see cosmic background radiation to energetically (and using colourful language) rebut a claim that the Big Bang is just a theory and may not have happened: “YOU CAN JUST ****** SEE IT.” As a newly qualified doctor on my first surgical firm, I worked with the team that had led the development of highly selective vagotomy as a curative treatment for peptic ulcer. In addition to the small operative mortality, many of the patients were left with long-term side effects such as malabsorption or diarrhoea. If I had dared to suggest that peptic ulcer might be a consequence of infection and amenable to curative treatment with antibiotics I would have been ridiculed, or worse. And yet this was subsequently found to be true and most patients are now successfully treated by H.pylori eradication rather than surgical intervention. The lessons I draw for my public health practice is that we should beware of our hidden prejudices and the influence of received wisdom; we should always be willing to challenge our assumptions. Other, less noble reasons for ignoring evidence include laziness, incompetence, pressure of work, and vested interests in outcomes; all issues that we should recognise and guard against as part of the ethical management of our own work.

Sometimes the evidence is rock solid but it is still not used to drive population health. The classic example must be smoking; we have known about the link between smoking and lung cancer since the work of Doll and Hill in the 1950s. But it took until 2007 for smoke-free public places to be enshrined in legislation across the UK. The 10-year anniversary of this achievement is an opportunity to recognise and celebrate its impact but also to raise the important question about where accountability lies for the thousands of avoidable deaths that have resulted from the decades-long delay in effective action. The answer seems to be “nowhere”. It seems to me that there is a failure in public sector governance if there is no accountability for inaction in the face of convincing evidence. The horrific events at Grenfell Tower perhaps serve as a more recent example.

And, of course, the evidence base is never complete, and we are often faced with contradictory evidence that steers us towards different courses of action. The recent debate about regulation of electronic cigarettes is a useful example. Evidence of the benefits as a smoking cessation aid have to be balanced by currently unquantifiable risks including the direct and indirect effects of vaping, and the potential for a new generation of young people to become addicted to nicotine. When faced with these sorts of uncertainty we have several options. We can commission further research, but that takes time. We can use a trial and error approach, but that brings risk (think of the death and illness last year of fit young volunteers in pharmaceutical trials in France). We can use a risk management and mitigation approach – something we all do unthinkingly in our daily lives when we buckle our seatbelts. And we can use a precautionary approach but, if used inappropriately, this might stifle innovation and change that could have a positive impact on population health.

Our approach in Wales has been to follow the thread of evidence-based public health action, from our research and development commitments (£43m per year), through the programme of action for our government, the legislative framework of the Wellbeing of Future Generations Act which requires public bodies to plan and report on population health outcomes, then through to our recently passed Public Health Act which has incorporated health impact assessment into our policy and planning. In Wales, we believe that evidence matters, but judgment and compassion also need to factor into our decision-making.

Disclaimer

The aim of this blog is to encourage discussion and debate on public health issues. The views expressed here are the personal views of authors, and the content does not reflect the official position of the Faculty of Public Health. However, discussion generated here may be used to influence the development of organisational policy.